HospitalInspections.org

Based on record review and interview, facility staff failed to thoroughly investigate all patient complaints and grievances and protect patients from potential abuse in 3 of 4 caregiver misconduct allegations reviewed (Patient (Pt) #1, #2, #3) in a total of 4 caregiver misconduct allegations reviewed; and failed to ensure that staff training for caregiver abuse and neglect addresses the process for immediately reporting in 1 of 1 abuse and neglect training reviewed (initial orientation), in a total of 1 abuse and neglect training reviewed.

Findings include:

The facility staff failed to thoroughly investigate all patient complaints and grievances and protect patients from potential abuse. SEE TAG A-0145

The facility staff failed to ensure that staff training for caregiver abuse and neglect addresses the process for immediately reporting. SEE TAG A-0145

Based on record review and interview, facility staff failed to thoroughly investigate all patient complaints and grievances and protect patients from potential abuse in 3 of 4 caregiver misconduct allegations reviewed (Patient #1, #2, #3) in a total of 4 caregiver misconduct allegations reviewed; and failed to ensure that staff training for caregiver abuse and neglect addresses the process for immediate reporting in 1 of 1 abuse and neglect training reviewed (initial orientation), in a total of 1 abuse and neglect training reviewed.

Findings Include:

A review of the facility's policy titled, "Patient Rights and Responsibilities" last revised 6/21/2024 revealed, "...Patients have the right, consistent with laws and regulations, to...be assured of reasonable safety within the care setting, including the right to be free from harassment, mental, physical, sexual, and verbal abuse, neglect, mistreatment, exploitation, humiliation, and retaliation..."

A review of the facility's policy titled, "Patient Complaints and Grievances" last revised 10/14/2022 revealed, "... If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action, then the complaint is a grievance for the purpose of these requirements... A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient ...regarding patient care... abuse or neglect...If the complaint cannot be resolved immediately by the associate, the associate will assist and assure the patient that the leader of the area where the patient is being treated will promptly be made aware of the complaint. If possible, the leader will immediately address the complaint... If the complaint is reported after the patient has been discharged, an associate may refer directly to the unit/department leader or designee to follow up on and manage. All complaints and grievances will be documented in the Salesforce Service Cloud as a patient feedback case. The department leader or designee will provide relevant documentation related to the grievance. This includes but is not limited to written statements of patients or persons involved. The unit/department leader or designee will assure the grievance has been assigned to the correct department(s) for appropriate follow up... Investigation should include review of medical records as well as interviews with associates, providers, and other department associates as appropriate that were involved or can offer input into the concern. Dept (department) leaders should be documenting when they make contact with others/who they contact/outcome of that follow up into the Follow-up Review Form to show actions they took to complete review..."

A review of the facility's policy titled, "Caregiver Misconduct and Injuries of Unknown Source Investigations and Reporting" last revised 4/28/2023 revealed, "...All caregivers providing services to patients in acute care facilities... must possess the knowledge and ability to identify and immediately report to the appropriate person all allegations of caregiver misconduct and injuries of unknown source...Any individual who becomes aware of an instance of suspected caregiver misconduct or allegation thereof or injury of unknown source shall immediately report the incident to the Charge Nurse, Department Supervisor/Manager/Director and/or Administrator-On-Call. The incident will be entered into the current reporting platform as applicable... Risk Management should be notified by providing the patient complaint number assigned to the incident, so support related to investigating the Incident can be provided. Risk Management will notify Human Resources and the [Facility name] Office of General Counsel of all reported incidents. When an individual becomes aware of the Incident and if the patient/client is physically located within an [Facility name] entity, a health care provider should immediately assess the patient/client and evaluate the nature of the allegation and/or extent of the reported injury... A thorough investigation may include... Collecting and preserving any physical evidence... Interviewing alleged victims and witnesses... Identifying any involved individuals... involving other regulatory authorities... Reviewing other related items such as staffing schedules, personnel files and the patient's/client's medical record... Documenting each step taken during the investigation, as well as the results of the investigation..."

Review of Patient #2's medical record revealed that Patient #2 was admitted to the 4th floor inpatient unit on 2/5/2025 with a chief complaint of shortness of breath and flu-like symptoms. Patient #2 was discharged on 2/7/2025 at 2:00 PM.

Review of the facility Caregiver Misconduct Investigation of PCT A authored by Risk Manager J, and staff interviews revealed:

· On 2/7/2025 at 7:09 PM, RN H sent an email to RN Manager G. " ...(Patient #2) made a few complaints about (PCT A's) behavior during our shift prior to being discharged. She stated that he said she was fine and specifically that 'black don't crack'... (PCT A) proceeded to ask her if she had children and how many she has... (PCT A) closed her room door to take her blood sugar and she told him to 'leave the door open.' (Patient #2) also stated that he asked if she wanted her sheets changed and she told him 'No, they were just changed.' According to the patient he came back two different times with clean linens... Both times he offered to change her sheets he offered to help her 'get cleaned up'... (Patient #2) stated to me that she felt very uncomfortable and did not want him in her room again with the door closed. The patient was shortly after this conversation being discharged, so I informed (House Supervisor I) and told (Patient #2) to call me directly if anything happened again and I would be right there." No further investigation, Adverse Event, or Complaint or Grievance were filed at the time of the report.

· On 2/10/2025 (No Time) (2 days after Patient #2's Complaint) RN Manager G investigated Patient #2's complaint. RN Manager G attempted to contact Patient #2 one time which was unsuccessful, with no returned call. No Adverse Event, or Complaint or Grievance was filed.

· On 2/10/2025 PCT A worked from 7:00 AM - 7:00 PM.

· On 2/12/2025 (No Time) (4 days after Patient #2's Complaint) RN Manager G had a coaching conversation with PCT A. PCT A denied Patient #2's allegations.

· RN M reported on 02/21/2025 at 10:01 PM that Patient #1 reported to RN M that after her previous admission (on 02/17/2025) someone who worked at the hospital contacted Patient #1 on her cell phone and sent 4 pictures of himself including a nude photo. Patient #1 showed RN M the photos, and RN M confirmed the pictures were of PCT A.

· On 2/24/2025 at 1:13 PM (17 days after Patient #2's Complaint) RN Manager G forwarded RN H's email to Risk Management.

· In an interview 02/25/2025 (no time) RN Manager G revealed, "(Manager G) came to writer's office ...and reported he and (RN Assistant Manager B) were talking and recall a patient (Patient #3) from 2 weeks ago. (Patient #3) has mental health history and some confusion." Per the interview with Manager G, (Patient #3) showed (Manager B) a piece of paper with a (phone) number that matched the same number of the phone used to send Patient #1 the pictures and a nude photo (of PCT A). Per interview with Manager G, just before discharge on 2/4/2025 Patient #3 told Manager G that a man had grabbed her breasts, but family refused an investigation at that time stating she was "confused" and "says things like that." No further investigation, Adverse Event, or Complaint or Grievance was filed at the time of the report.

· On 2/26/2025 (No Time) (19 days after Patient #2's Complaint) Risk Management interviewed Patient #2 and learned that in addition to making Patient #2 feel uncomfortable with comments, PCT A also "was taking her blood sugar (and) he was running his had up/down her arm and leg" and PCT A offered to give Patient #2 a "bubble bath."

· A phone interview on 02/27/2025 (no time) with (Patient #3's daughter), revealed that after discharge (Patient #3) informed her that a "male was touching her, wiping between her legs..." (Patient #3's daughter) stated Patient #3 told her that the male associate did a "good job with the bath ...made it like an accident when he touched her privates." Per (Patient #3) the male associate gave Patient #3 his telephone number to contact him after discharge (the number that was given to Patient #3 was the same number that sent the nude photos of PCT A to Patient #1).

· Review of Pt #3's medical record revealed PCT A documented assisting Pt #3 with a "bath" on 2/1/2025 and 2/2/2025.

An interview was conducted on 4/29/2025 at 9:08 AM with Risk Manager J. When asked about the investigation timeline that Risk Manager J wrote for PCT A's caregiver misconduct, Risk Manager J stated that when she received notification of the event on 2/24/2025, she entered an ERS (Event Reporting System), as it had not been done previously. Risk Manager J stated that the facility did not know about the case until Patient #1 reported it on 2/21/2025. Risk Manager J stated that based on the facility's investigation, all information gathered from event details with Patient #1, Patient #2, and Patient #3 pointed to PCT A committing Caregiver Misconduct. Risk Manager J stated that the decision was made jointly by the Risk Department, HR, and General Council that there was substantiation of the allegations. Risk Manager J stated that PCT A was suspended on 2/24/2025, and terminated on 3/2/2025. Risk Manager J stated that PCT A did not work at the facility between 2/21/2025 and 3/2/2025.

Review of the Caregiver Misconduct Investigation Report for PCT A, revealed that Patient #2's complaint regarding PCT A was shared with the nurse on 02/07/2025 and staff did not immediately escalate to leadership and enter the complaint in the reporting system for follow up as per policy. Manager G was not informed of the complaint until 3 days later and there was no documented evidence of Manager G investigating Patient #2's complaint as per policy, including interviewing the patient, staff, and witnesses. Patient #2 was not interviewed by staff until 02/26/2025 (19 days later), during which time it was discovered that 2 additional patients (Patient #1 and Patient #3) had come forward with caregiver misconduct and abuse allegations against PCT A.

Review of PCT A's schedule revealed that PCT A worked his full time schedule unrestricted between the dates of 2/7/2025 (the date Patient #2 complained) and 2/21/2025 (the date Patient #1 reported to facility staff that she had been contacted by PCT A and received a nude photo from PCT A.)

An interview was conducted on 4/28/2025 at 2:10 PM with 4th Floor RN H. When asked about the email that RN H sent on 2/7/2025, RN H stated that before she sent the email, she reported the concern about PCT A's inappropriate interaction with Patient #2 to House Supervisor I. RN H stated that she did not enter the concern into the ERS. RN H stated that she did not know if House Supervisor I took any immediate action on the concern, but that he instructed RN H to email RN Manager G, Assistant RN Manager B, and RN Lead F. RN H stated she then sent the email at the end of her shift. RN H told Patient #2 that she was going to report it to her Manager, and that Patient #2 agreed that was a good idea.

An interview was conducted on 4/28/2025 at 2:30 PM with 4th Floor RN Manager G. RN Manager G stated that he recalled getting the email regarding Patient #2's complaint dated 2/7/2025 sent by RN H, but that he was off duty (on a Friday evening at 7:09 PM) at the time, and did not see it until he was next on duty on Monday 2/10/2025. RN Manager G stated that he worked on investigating the case on 2/10/2025 and felt at the time that since Patient #2 had been discharged, there was no need to make changes in PCT A's patient assignment. In a later interview on 4/30/2025 at 9:30 AM, RN Manager G stated that he attempted to contact Patient #2 once during the investigation, but never heard back from her. RN Manager G stated that he followed up with PCT A on 2/12/2025 regarding the reported interaction that made Patient #2 feel uncomfortable. RN Manager G stated that PCT A denied knowing that his interactions with Patient #2 were inappropriate or that it made Patient #2 feel uncomfortable. RN Manager G stated that he coached PCT A on interactions with patients, and told him that he should always ask patients if they feel comfortable having the door open/closed, patients have a right to refuse cares, and that refusal should be documented in the electric medical record. RN Manager G stated that he didn't recall any further follow-up conducted at that time. RN Manager G stated he did not enter an ERS for the 2/7/2025 incident.

An interview was conducted on 4/29/2025 at 12:10 PM with House Supervisor I. When asked about RN H coming to him on 2/7/2025 with a complaint of from Patient #2 about PCT A, House Supervisor I stated that at the time the information did not give him too much concern, and that Patient #2 was discharged about 2 hours after the report. House Supervisor I stated that he did not confront PCT A or enter an ERS, because he "did not have enough information to do so." House Supervisor I stated that he instructed RN H to send the complaint in an email to RN Manager G, RN Lead F, and Assistant RN Manager B.

A review of the facility training modules on 4/29/2025 at 11:35 AM revealed that all staff receive education yearly on "Abuse and Neglect" and "Annual Compliance." Information in the modules included definitions of the "Vulnerable Adult, Sexual Abuse, and Verbal and Non-Verbal Harassment." The modules also included Reporting responsibilities of every staff member, and that all staff should report suspected misconduct to their supervisors, and that staff "can enter an ERS." No timelines for reporting were noted.

An interview was conducted on 4/29/2025 at 11:55 AM with Education Specialist P who stated that there is no reference of the Caregiver Misconduct Policy in the Annual training. Education Specialist P stated that the Facility tends to be more reactive with training staff about Caregiver Misconduct when events take place, rather than offering broad proactive training.